197610382-4-6-2023-31-AS-JGTN-CQMTNK-20230406145251

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610382
Report Date: 04/06/2023
Date Signed: 04/06/2023 02:53:38 PM

Document Has Been Signed on 04/06/2023 02:53 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	LIFELONG SENIOR LIVING		FACILITY NUMBER:	197610382
ADMINISTRATOR:	KAPIKYAN, ANDRANIK		FACILITY TYPE:	740
ADDRESS:	16003 LUDLOW STREET		TELEPHONE:	(747) 203-4493
CITY:	GRANADA HILLS	STATE: CA	ZIP CODE:	91344
CAPACITY:	6	CENSUS: 0	DATE:	04/06/2023
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	11:48 AM
MET WITH:	Andranik Kapikyan - Licensee Representative		TIME COMPLETED:	03:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Gary Tan conducted an announced Pre licensing visit to this facility and met with Licensee representative Andranik Kapikyan. The applicant is "Lifelong Senior Living". Fire Clearance dated 02/21/23 was received for six (5) non-ambulatory residents, one (1) of which may be bedridden on room #2. Bedroom #4 is cleared for ambulatory only. Purpose of today’s visit is to inspect the facility to ensure that the facility is in compliance with the rules and regulations of California Code of Regulations, Title 22, Division 6. Facility is a single storey home. At 11:56 AM, Site visit was conducted by the LPA which consisted of touring the physical plant inside and outside and observed the following: The facility smoke alarm system is hard wired and interconnected. The fire extinguisher is located in the wall of the living room and was observed to be fully charged and last bought on 11/09/2022. Carbon Monoxide detector was observed located near the entrance door, tested and observed to be operational. Hot water was tested in the common bathroom and measured at a range of 116.7°F to 118.9°F. There is a functioning telephone on the premises. An emergency exit plan/sketch is posted on the hallway wall with other posting requirements. There are four (4) resident bedrooms, two (2) private and two (2) shared. Resident bedrooms were observed to be appropriately furnished. The common areas (living room, kitchen and dining areas) were appropriately furnished and lighting was adequate. The living room has a television and comfortable furniture. Resident and staff records will be stored in a locked filing cabinet in the back area. Medications will be stored in the locked storage near the main entrance door. The first aid kit is readily available. There are two (2) bathrooms in the facility. The common bathroom has non-skid mat and appropriate grab bars installed. (continued to LIC 809-C)

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Jose Gary Tan	TELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:	DATE: 04/06/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/06/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 2

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: LIFELONG SENIOR LIVING	FACILITY NUMBER: 197610382
	VISIT DATE: 04/06/2023

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

(continued from LIC 809)

The kitchen knives are stored in a locked drawer in the kitchen. Kitchen cleaning supplies are stored in a locked cabinet under the kitchen sink. Laundry detergents, cleaning supplies and other toxins are stored in the locked storage adjacent to the kitchen. The laundry area is located in the side alley within the compound. The necessary precautions have been made to the facility to safely house dementia residents such as auditory alarms on all doors and locked areas for centrally stored medications. Facility appears to be clean and in good repair. Appliances in the kitchen appeared to be functional.

There is a sitting area in the backyard for residents to conduct outdoor activities. The backyard is fenced. There is no garage at the facility, only driveway. The garage is not a part of facility, it is on the process of being converted to an Additional Dwelling Unit (ADU) by the property owner with permit from appropriate authorities and will have a different address. There is no body of water in the facility.

The request for Component III to be waived at this facility has been granted by LPM Naira Margaryan as this Licensee is currently the administrator of another licensed facility.

Facility is in compliance with Title 22 Regulations at this time. This report will be forwarded to the Centralized Application Bureau (CAB). You will be notified by the CAB Analyst when your license has been approved.

Exit interview conducted. Copy of this report issued.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Jose Gary Tan	TELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:	DATE: 04/06/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/06/2023

LIC809 (FAS) - (06/04)

Page: 2 of 2